A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?
Increased BUN
Increased urine ketones
Decreased urine specific gravity
Decreased Hgb
The Correct Answer is A
Choice A Reason: This is correct because BUN stands for blood urea nitrogen, which is a waste product of protein metabolism that is excreted by the kidneys. Increased BUN indicates fluid volume deficit, as the blood becomes more concentrated and the kidneys have less fluid to filter. A normal BUN level is 7 to 20 mg/dL. The nurse should monitor the client's fluid intake and output, weight, and serum electrolytes, and administer fluids as ordered.
Choice B Reason: This is incorrect because urine ketones are not related to fluid volume deficit, but to diabetic ketoacidosis, which is a complication of diabetes mellitus that occurs when the body breaks down fat for energy and produces ketones as a by-product. Increased urine ketones indicate diabetic ketoacidosis, which can cause
dehydration, acidosis, and coma. A normal urine ketone level is negative or trace. The nurse should monitor the client's blood glucose, pH, and bicarbonate levels, and administer insulin and fluids as ordered.
Choice C Reason: This is incorrect because urine specific gravity is a measure of the concentration of solutes in the urine. Decreased urine specific gravity indicates fluid volume excess, as the urine becomes more diluted and the kidneys excrete more fluid. A normal urine specific gravity range is 1.005 to 1.030. The nurse should monitor the client's fluid balance, vital signs, and edema, and administer diuretics as ordered.
Choice D Reason: This is incorrect because Hgb stands for hemoglobin, which is a protein in red blood cells that carries oxygen. Decreased Hgb indicates anemia, which is a condition that occurs when the blood has a low number of red blood cells or hemoglobin. Anemia can cause fatigue, weakness, and pallor. A normal Hgb level for adult males is 14 to 18 g/dL and for adult females is 12 to 16 g/dL. The nurse should monitor the client's oxygen saturation, iron level, and blood transfusion needs, and administer iron supplements or erythropoietin as ordered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A: Bicarbonate excess is a sign of metabolic alkalosis, because this condition occurs when the body has too much bicarbonate or loses too much acid. This can happen in patients who have excessive vomiting, gastric suctioning, diuretic therapy, or antacid intake.
Choice B: Lethargy is a sign of metabolic alkalosis, because this condition affects the central nervous system and causes decreased level of consciousness, confusion, and drowsiness. Lethargy can also result from hypoxemia, which is a condition that occurs when the blood oxygen level is too low. This can happen in patients with metabolic alkalosis who have respiratory compensation and hypoventilation.
Choice C: Kussmaul's respirations are not a sign of metabolic alkalosis, but rather of metabolic acidosis. This is a condition that occurs when the body produces too much acid or loses too much bicarbonate. This can happen in patients who have diabetic ketoacidosis, renal failure, or lactic acidosis. Kussmaul's respirations are deep, rapid, and labored breathing that help to eliminate excess carbon dioxide and acid from the blood.
Choice D: Circumoral paresthesia is a sign of metabolic alkalosis, because this condition causes hypocalcemia, which is a condition that occurs when the blood calcium level is too low. This can happen in patients with metabolic alkalosis who have increased binding of calcium to albumin due to alkaline pH. Circumoral paresthesia is a tingling sensation around the mouth that indicates neuromuscular irritability.
Choice E: Flushing is not a sign of metabolic alkalosis, but rather of hypercalcemia, which is a condition that occurs when the blood calcium level is too high. This can happen in patients who have hyperparathyroidism, malignancy, or excessive calcium intake. Flushing is a reddening of the skin that indicates vasodilation and increased blood flow.
Correct Answer is A
Explanation
Choice A: Widened QRS complexes is correct because it is a sign of cardiac dysrhythmias, which can occur in respiratory acidosis due to hyperkalemia, or high potassium level. Respiratory acidosis is a condition where the blood pH is low and the PaCO2 is high, indicating impaired gas exchange or hypoventilation. This can cause potassium to shift from the intracellular fluid to the extracellular fluid, thus raising the serum potassium level and affecting the cardiac conduction.
Choice B: Hyperactive deep tendon reflexes is incorrect because it is a sign of hypocalcemia, or low calcium level, which can occur in metabolic alkalosis, not respiratory acidosis. Metabolic alkalosis is a condition where the blood pH is high and the HCO3 is high, indicating a loss of metabolic acids or an excess of bicarbonate in the body. This can cause calcium to bind to albumin and lower its availability in the blood, thus increasing the neuromuscular excitability.
Choice C: Bounding peripheral pulses is incorrect because it is a sign of fluid overload, which can occur in heart failure, not respiratory acidosis. Fluid overload is a condition where the fluid volume in the body exceeds the normal range, causing edema, hypertension, and dyspnea. This can be caused by conditions such as kidney disease, liver disease, or excessive sodium intake.
Choice D: Warm, flushed skin is incorrect because it is a sign of vasodilation, which can occur in respiratory alkalosis, not respiratory acidosis. Respiratory alkalosis is a condition where the blood pH is high and the PaCO2 is low, indicating excessive loss of carbon dioxide through hyperventilation. This can cause the blood vessels to dilate and increase the blood flow to the skin, thus causing warmth and redness.
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